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Acute Renal Failure, Fluid Management and Renal Replacement Therapy

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Title: Acute Renal Failure, Fluid Management and Renal Replacement Therapy


1
Acute Renal Failure, Fluid Management and Renal
Replacement Therapy
  • ??????????
  • ???
  • V.S???

2
Outline
  • Renal function
  • Acute renal failure
  • Complication of ARF
  • Management
  • Renal replacement therapy

3
?????
  • ????
  • ????
  • ?????
  • ?????
  • ????? Vitamin D, erythropoietin

4
Outline
  • Renal function
  • Acute renal failure
  • Complication of ARF
  • Management
  • Renal replacement therapy

5
Definition
  • rapid (hours to weeks) decline in glomerular
    filtration rate and retention of waste products
  • Lack a uniform definition
  • Cr gt 1.5x, urine output lt.5ml/kg/hr
  • Cr increase 1.0 mg/dl/2d
  • Incidence
  • 5 of hospital admission
  • up to 30 of admission to intensive care units.

6
Prerenal azotemia
  • Intravascular volume depletion (hypovolemia)
  • Major trauma, burns, crush syndrome, hemorrhage,
    dehydration
  • GI fluid loss vomiting, surgical drainage,
    diarrhea
  • Renal fluid loss diuretics, osmotic diuresis,
    adrenal insufficiency
  • Sequestration of fluid in extravascular space
    pancreatitis, peritonitis, hypoalbuminemia

7
Classification of Renal Failure
  • (1)  Prerenal abnormality (Prerenal azotemia)
    disorder of renal hypoperfusion which
    intrinsically normal
  • (2)   Intrinsic renal abnormality (renal
    azotemia) disease of the renal parenchyma
  • (3)   Postrenal abnormality (postrenal azotemia)
    acute obstruction of urinary tract

8
Prerenal Azotemia
  • Decreased cardiac output (low cardiac output)
  • Severe congestive heart failure or low cardiac
    output syndrome myocardial failure, valvular or
    pericardial disease, including arrhythmias and
    tamponade
  • Pulmonary hypertension, massive pulmonary
    embolism
  • Positive pressure mechanical ventilation

9
Prerenal Azotemia
  • Increased renal /systemic vascular resistance
    ratio
  • Systemic vasodilatation sepsis, antihypertensive
    agents, afterload reducers, anesthesia,
    anaphylaxis
  • Renal vasoconstriction hypercalcemia,
    norepinephrine, epinephrine, cyclosporin,
    amphotericin B
  • Liver cirrhosis with ascite

10
Prerenal Azotemia
  • Increased blood viscosity (hyperviscosity
    syndrome)
  • Multiple myeloma, macroglobulinemia, polycythemia
  • Renal hypoperfusion with impairment of renal
    autoregulatory responses
  • Renal artery obstruction artherosclerosis,
    embolism, thrombosis, dissecting aneurysm
  • Cyclooxygenase inhibitors, angiotension-converting
    enzyme inhibitors

11
Intrinsic Azotemia
  • Acute tubular necrosis
  • Ischemia as for prerenal azotemia, obstetrical
    complication (abruptio plancentae, postpartum
    hemorrhage)
  • Nephrotoxic damage contrast media, antibiotics
    (e.g. aminoglycosides, amphotericin B),
    cyclosporine, chemotherapeutic agents( e.g.
    cisplatin), organic solvents (e.g. Ethylene
    glycol), heavy mental, snake venom, mushrooms,
    sulfonamide
  • Pigment nephropathy myoglobin,
    hemoglobin tumor-specific syndrome plasma cell
    dyscrasia, tumor lysis

12
Intrinsic Azotemia
  • Disease of glomeruli or renal microvasculature
  • Glomerulonephritis and vasculitis
  • Hemolytic uremic syndrome, thrombotic
    thrombocytopenic purpura, disseminated
    intravascular coagulation, toxemia of pregnancy,
    accelerated hypertension, radiation nephritis,
    scleroderma, systemic lupus erythematosus

13
Intrinsic Azotemia
  •   Interstitial nephritis
  • Allergic antibiotics (e.g. beta-lactams,
    sulfonamides, trimethoprime, rifampicin),
  • Cyclooxygenase inhibitors, diuretics, captopril
  • Infection bacterial (e.g. acute pyelonephritis,
    leptospirosis), viral (e.g. CMV), fungal
  • Infiltration lymphoma, leukemia, sarcoidosis

14
?????
  • Intrinsic Azotemia

15
Intrinsic Azotemia
  • Renal vein obstruction thrombosis, compression
  • Intratubular deposition and obstruction
  • myeloma proteins, uric acid, oxalate, acyclovir,
    methotrexate

16
Postrenal Causes of Renal Failure
  • Obstruction of ureters
  • Extraureteral tumor cervix, prostate,
    endometriosis Periureteral fibrosis
    (retroperitoneal fibrosis) accidental ureteral
    ligation during operation Intraureteral stone,
    blood clots, pyogenic debris, papillary necrosis
  • Bladder neck obstruction
  • Neurogenic bladder, bladder carcinoma, prostate
    hyperplasia, calculi
  • Urethral obstruction
  • Stricture, phimosis, congenital valve, tumor

17
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18
Symptoms and Signs
  • Retention of nitrogenous waste products
  • Nausea, vomiting, diarrhea, hiccup, foul taste,
    dry crusted mouth, itching,
  • Drowsiness, clouding of consciousness,
    neuropathy, pericarditis, GI bleeding,
  • Coma
  • Retention of salt and water
  • Pulmonary edema, peripheral edema, ascites,
    pleural effusion

19
Symptoms and Signs of Renal Failure
  • Retention of potassium
  • Weakness, lassitude, paralysis, EKG changes with
    tenting T waves, widening of
  • QRS complex, increased PR interval, sine wave
    pattern, cardiac arrest, VT
  • Retention of acid
  • Kussmaul respiration, hyperreflexia, hypotension

20
  • Edema
  • Impairment of renal function

21
Outline
  • Renal function
  • Acute renal failure
  • Complication of ARF
  • Management
  • Renal replacement therapy

22
Complications of Renal Failure
  • Cardiopulmonary complication
  • Metabolic complication
  • Gastrointestinal complication
  • Neurogenic complication
  • Hematological complication
  • Infection

23
Cardiopulmonary Complications
  • Cardiovascular
  • Pulmonary edema
  • Arrhythmia
  • Hypertension
  • Pericardial effusion
  • Myocardial infarction
  • Pulmonary embolism
  • Congestive heart failure

24
Hypertension and Edema
  • Inability of the kidney to excrete sodium ? blood
    volume ? ? hypertension and edema

25
Metabolic Complications
  • Metabolic
  • Acidosis
  • Hyponatremia
  • Hyperkalemia
  • Hypocalcemia
  • Hyperphosphatemia
  • Hypermagnesemia
  • Hypomagnesemia
  • Hyperuricemia

26
Metabolic Acidosis
  • Inability of the kidney to secrete hydrogen ions
    and conserve bicarbonate

27
Hyperkalemia
  • K competes with H for Na exchange ? Tubular
    excretion of potassium ? ? Hyperkalemic acidosis
  • Excretion of aldosterone ? ? Excretion of
    potassium in collecting duct ? ? Hyperkalemia

28
Gastrointestinal Complications
  • Gastrointestinal
  • Nausea
  • Vomiting
  • Gastritis
  • Gastroduodenal ulcer
  • Gastrointestinal bleeding
  • Malnutrition

29
Neurogenic Complications
  • Neurogenic
  • Asterixis
  • Neuromuscular irritability
  • Mental status changes
  • Somnolence
  • Coma
  • Seizure

30
Hematological Complications
  • Hematological
  • Anemia
  • Hemorrhagic bleeding
  • Infection
  • Pneumonia, septicemia
  • Urinary tract infection, wound infection

31
Anemia
  • Erythropoietin decrease
  • Erythropoietin stimulates bone marrow to produce
    red blood cells.
  • Toxic wastes suppress the ability of bone marrow
    to produce red blood cells.

32
Bleeding
  • Platelet abnormality
  • Normal or a little decreased platelet number
  • Platelet dysfunction
  • Epistaxis, GI bleeding, bruising, hemoptysis

33
ARF VS ALI
  • Mortality
  • ARF 30-40
  • ALI 35
  • BOTH 80

34
ARF VS ALI
  • Effect of ARF on lung ( Experimental studies)
  • Increase pulmonary vascular permeability,
    macrophage medicated in part
  • Salt and water transporters disorder lung fluid
    retention

35
ARF VS ALI
  • Effect of mechanical ventilator on kidney (
    Experimental studies)
  • Systemic hemodynamic change( VR, CO )
  • Anti-natriuretic, anti-diuretic effect
  • Augmentation of inflammatory milieu

36
Outline
  • Renal function
  • Acute renal failure
  • Complication of ARF
  • Management
  • Renal replacement therapy

37
Management
  •    Prevention
  •    Etiology treatment
  •    Prevention additional injury
  •    Establish diuresis
  •    Treatment of complication
  •    Conservative measurement
  •    Renal replacement therapy

38
Prevention
  • Identification of high-risk patients for
    pharmacologic agents-induced nephrotoxicity
  • iodinated radiocontrast medium, NSAIDs
  • Aggressive surveillance for nephrotoxin-induced
    renal dysfunction
  • cisplatin, amphotericin B, aminoglycoside
  • Use of volume expansion in selected clinical
    settings
  • Hyperpigmenturia hemoglobinuria, myoglobinuria
  • Crystaluria uric acid, acyclovir, methotrexate,
    sulfonamides
  • Minimalization of catheters use to avoid
    nosocomial sepsis

39
Etiology Treatment
  • Correct postrenal factor
  • Correct prerenal factor
  • Treat underlying sepsis
  • Stop nephrotoxic drugs

40
Establish Diuresis
  • Volume expansion/hydration
  • osmotic diuretics and loop diuretics mannitol,
    furosemide
  • renal vasodilators dopamine (1-2ug/kg/min),
    atrial natriuretic peptid

41
Evaluation of intravascular volume
42
Guide of Volume Expansion
  • CVP 8-14 cm H2O (5-2 rule)
  • PAWP 12-16 mmHg (7-3 rule)
  • Urine output 0.5-1.0ml/kg/hour
  • Weighing the patient daily
  • Insensible water loss from the skin and
    respiratory tract (500 ml/day)

43
Conservative Measurement
  • Fluid balance
  • Careful monitoring of I/O and body weight
  • Fluid restriction
  • (usually less than 1 L/day in oliguric ARF)
  • Total intake lt urine output extrarenal losses
  • Electrolytes and acid -base balance
  • hyperkalemia
  • hyponatremia
  • Keep serum bicarbonate gt15
  • hyperphosphatemia
  • Treat hypocalcemia only if symptomatic

44
Dietary modification
  • total caloric intake 35 50 kcal/kg/day
  • to avoid catabolism
  • Salt restriction 24 g/day
  • Potassium intake 40 meq/day
  • Phosphorus intake 800 mg/day

45
Conservative Measurement
  • Uremia-nutrition
  • Restriction protein but maintain caloric intake
  • Carbohydrate 100gm/day to minimize ketosis and
    protein catabolism
  • Drug
  • Review all medication, Stop magnesium-containing
    medication
  • Adjusted dosage for renal failure, Readjust with
    improvement of GFR

46
Outline
  • Renal function
  • Acute renal failure
  • Complication of ARF
  • Management
  • Renal replacement therapy

47
Indications for Renal Replacement Therapy
  • Prophylactic dialysis BUN 80-100 mg/dl ,
    creatinine 8-10 mg/dl
  • Volume overloading with refractory to diuretics
  • Pulmonary edema
  • Hyperkalemia gt 6.5 mEq/l
  • Severe metabolic acidosis lt 7.2

48
Indications for Renal Replacement Therapy
  • Uremic pericarditis
  • Uremic encephalopathy coma, seizure
  • Acute uric acid nephropathy

49
Methods for Renal Replacement Therapy
  • Intermittent hemodialysis
  • Peritoneal dialysis
  • Continuous renal replacement therapy
  • CAVH/CAVHD/CVVHDF, CVVH/CVVHD/CVVHDF

50
Mechanisms
  • diffusion movement of solute towards the same
  • concentration on each side of
    membrane.
  • convection solute is carried together
    with solvent
  • across the membrane by
    filtration.
  • ultrafiltration plasma water and
    crystalloids separated
  • from the whole blood across a
    semipermeable
  • membrane in response to a TMP.
  • osmosis operates in peritoneal dialysis.
  • ( glucose is the osmotic agent )

51
HD
HF
HDF
HFD
52
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53
Intermittent hemodialysis in ARF and critically
ill patients
54
Peritoneal dialysis
  • infusion of pyogen-free solution into the
    peritoneal cavity, drained in subsequent cycles.
  • Mechanism diffusion, convection, and osmotic
    ultrafilation
  • Modalities intermittent peritoneal dialysis (
    IPD ), continuous equilibrated peritoneal
    dialysis ( CPD ), tidal peritoneal dialysis ( TPD
    ).
  • Indications patients at risk of bleeding
  • fluid overload in CV
    instability

55
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56
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57
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58
Peritoneal dialysis
59
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60
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61
Continuous renal replacement therapy
  • ??
  • ????????????(CAVH)
  • ????????????(CVVH)
  • ????????????(CAVHD)
  • ????????????(CVVHD)
  • ??????????????(CAVHDF)
  • ??????????????(CVVHDF)

62
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63
CAVH
64
CVVH
65
Comparison of different CRRT Modalities
66
  • ??????????????????,??????( gt50)
  • ???????????,??????,????????????? (???, ??)
  • ??????????????
  • (1) ???????
  • (2) ???????????(?TPN)
  • CRRT????????????,?????????????(intermittent
    hemodialysis, IHD)??????

67
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68
CRRT ????
  • 1.?????
  • 2.?????????????
  • convective clearance (hemofiltration)
  • diffusive clearance (hemodialysis)
  • ??????(HDF)
  • 3.???????
  • arteriovenous v.s. venovenous

69
CRRT????
  • A. Renal indications
  • -hemodynamic instability
  • -multiple organs dysfunction syndrome
  • accompanied by renal failure
  • -acute renal failure with cerebral edema
  • B. Non-Renal indications
  • -possible removal of substances active as
    mediators

70
CRRT ???
  1. avoidance of electrolyte, water and urea
    fluctuation
  2. gradual urea removal
  3. hemodynamic stability with slow ultrafiltration
  4. optimal fluid balance and unlimited alimentation
  5. elimination of septic mediators
  6. lower intracranial pressure
  7. improved outcome

71
CRRT???
  • ?????(?CAVHD)
  • ?????(???????)
  • limited mobility
  • slower solute and fluid removal
  • ???????

72
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73
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74
?????? (replacement fluid)
  • ?? plasma water
  • approximate normal plasma water composition,
    replacing electrolytes and minerals
  • ????????
  • ???????????
  • ?????????

75
?????(1)
  • ?????????????,?????,????????????,?????????????????
    ?
  • ??????????????????????????????????
  • ???????????????????????

76
?????(2)
  • ??????????????,?????????????,?????????????????????
    ?????
  • ?? CV(A)VHD total sodium mass
  • transfer convection diffusion
  • (?? convection??)

77
?????(1)
  • ??????????????,??????
  • ??????,??,???? hypercatabolism,
  • GI bleeding, sepsis, hemolysis, hematoma,
  • crush syndrome???????????????
  • ??????? 1-2 mEq/L ?
  • ???????????????????????
  • ????????hypocalcemia,
  • hyponatremia, acidosis, hypermagnesemia
  • ????????????????????

78
?????(2)
  • ???????,????????? ??(30),??????????????,?????????
    ??????,?????????????
  • ??CRRT?????????????????????????,??????????(???)???
    ????

79
?????(3)
  • ??????????????????CRRT????????????????????????,??
    ????????????????????
  • ??????????,?????????,??????????

80
?????
  • ??hemofiltration?, ????????,??????(?70????)
  • ????????? 1.5-1.7 mEq/L

81
????
  • CVVHD ?? clearance 21.3 5.6 cc/min ( v.s. BUN
    25.3 cc/min , Cr 24.1 cc/min)
  • ??90?????,?????????????????
  • ???????????

82
??
  • 1. ?????????????????,???
  • ?????????????????,???
  • ?????????????
  • 2. ??hemofiltration ???, ?????
  • ???, ??????????????????????????hemodialysis?
    ????
  • ????????????????????

83
??
  • 3. ?????????????/????
  • ???????????????,?
  • ???????????,?????
  • ?,???????????
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